Nokea
A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, 'I guess we just don't get along.' Which of the following responses by the nurse is MOST appropriate?
- A. Your wife seems to be upset by the situation.
- B. Perhaps you should both go home now.
- C. Try to think about what precipitated her crying.
- D. The situation is difficult for both of you.
Correct Answer: D
Rationale: Acknowledging the emotional impact on both spouses fosters therapeutic communication without judgment. Options A, B, and C are less effective: A focuses only on the wife, B dismisses the situation, and C may provoke defensiveness.
You may also like to solve these questions
A 42-year-old man with metastatic lung cancer is admitted to the hospital. His orders include: do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. When the nurse assesses him, his BP is 86/50, respirations are 8, and he is nonresponsive. Naloxone hydrochloride (Narcan), 0.4 mg IV, is ordered STAT. In planning care for this man, it is IMPORTANT for the nurse to know that
- A. the BP and respirations will need to increase before a second dose of Narcan can be given.
- B. Narcan should not be given to the man because of his DNR status.
- C. a dose of Narcan may need to be repeated in 2-3 minutes.
- D. Narcan is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.
Correct Answer: C
Rationale: half-life of Narcan is short; may go back into respiratory depression; may need to be repeated
The nurse is planning care for a client with a long history of smoking and newly diagnosed chronic obstructive pulmonary disease (COPD). Which of the following should the nurse include in the client's teaching plan?
- A. Explain the need to avoid large crowds during the winter months.
- B. Instruct the client to install air conditioning in the home.
- C. Teach the client to breathe in through the nose and out through the mouth.
- D. Encourage the client to consume three large meals daily.
Correct Answer: A
Rationale: Clients with COPD are at high risk for respiratory infections, which can exacerbate symptoms. Avoiding large crowds during winter reduces exposure to viruses. Options B, C, and D are less relevant: air conditioning is not essential, nasal breathing is not specific, and large meals can cause dyspnea due to gastric pressure.
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
Which of the following actions, if taken by the nurse, is BEST?
- A. Recommend that the morphine dose be decreased.
- B. Withhold the pain medication.
- C. Administer the medication by another route.
- D. Explore alternative pain management techniques.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important
Which of the following meal choices is suitable for a 6-month-old infant?
- A. Egg white, formula, and orange juice
- B. Apple juice, carrots, and whole milk
- C. Rice cereal, formula, and apple juice
- D. Melba toast, egg yolk, and whole milk
Correct Answer: C
Rationale: Rice cereal, formula, and apple juice are appropriate for a 6-month-old, as they are easily digestible and safe. Egg whites, whole milk, and orange juice are not recommended before 1 year due to allergy and digestive risks.
The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.